"Serious failings" in infection control were responsible for the deadly spread of a hospital bug at Stoke Mandeville Hospital, according to an inquiry.
C. difficile caused diarrhoea
The Healthcare Commission said senior managers put NHS targets above outbreak control and failed to follow advice.
Two outbreaks of Clostridium difficile at the Aylesbury hospital resulted in at least 33 deaths, higher than the 12 previously thought.
The investigation was ordered by Health Secretary Patricia Hewitt.
The leadership of the trust compromised the safety of patients by failing to make the right decisions
Anna Walker, Healthcare Commission
CPS:LINK HREF="" ID="5209558" STYLE="rightarrow">C. difficile cases up
Cases of C. difficile infection in patients aged 65 years and above increased by 17.2% in England over the last year, from 44,107 in 2004 to 51,690 in 2005, according to figures released by the Health Protection Agency.
The bacterium usually cause diarrhoea but can lead to fevers or more serious infections.
The strain seen at Stoke Mandeville Hospital was relatively unknown, and appeared to cause more serious infections than other types.
Two outbreaks took place between October 2003 and June 2005, and overall 334 patients were infected and at least 33 died in this period. The death toll may have been as high as 65.
Did not follow advice
The Healthcare Commission's inquiry highlighted significant failings by the senior managers at the hospital, which forms part of the Buckinghamshire Hospitals NHS Trust.
The bacteria are naturally present in the intestine but kept under control by other bacteria
Antibiotics can kill some of these, allowing C.difficile to take hold
Overuse of antibiotics is linked to the infection's rise
C.difficile is not resistant to treatment, but some cases are difficult to treat
The strain seen at Stoke Mandeville hospital is related to one which has emerged in the US and Canada
It said they failed to follow advice on stopping the spread of infection, even at the height of the outbreak, from infection control staff, clinicians, nurses, and the Health Protection Agency.
The report added that the managers failed to learn lessons from the first outbreak of the bacterium.
It said they were too busy focusing on other areas, such as meeting government targets and finance control.
A major cause of the spread was because the hospital failed to isolate patients with the infection, and infected patients were also being moved from ward to ward.
Investigators also criticised inadequate cleaning, poor layout in older wards, a lack of hand washing and poor training in infection control.
Staff at the hospital told investigators they were "too rushed to answer call bells or change soiled sheets". Patients and relatives complained to the commission about dirty wards and toilet areas.
Anna Walker, chief executive of the Healthcare Commission, said: "At Stoke Mandeville, the leadership of the trust compromised the safety of patients by failing to make the right decisions, even though they had the benefit of experience from the first outbreak. They rejected the proper advice of their own experts.
"We fully recognise that these outbreaks are not easy to control. But we also know that trusts can minimise the spread of infection so long as they follow established advice on infection control."
In the wake of the outbreaks, the chief executive of the Buckinghamshire Hospitals NHS Trust and chair of the trust's board have left.
The Healthcare Commission has issued a series of recommendations, including:
- A review of criteria for transferring patients between wards
- A review of the way the board becomes aware of clinical risk
- Ensuring wards are properly cleaned and infection control is prioritised.
The trust has 60 days to complete meet these objectives.
Alan Bedford, the newly appointed acting chief executive of the trust, said: "We are determined to learn everything we can from the report, and fully accept the Healthcare Commission's recommendations that the outbreaks should have been handled better, and that there are organisational issues on which work is needed.
"Our priority is to work with staff on the issues raised by the report and to reassure patients that they are in safe hands."
Health Minister Andy Burnham said: "What happened at Stoke Mandeville is inexcusable and must not be allowed to reoccur."
The commission has also said these problems are not confined to Stoke Mandeville Hospital and all hospitals should urgently review their procedures for infection control.